Special Issues in Diabetes 203dietary behaviors to decrease caloric intake and consumption
of fats, and to increase intake of dietary “ber, (b) engaging in
low-impact exercise such as walking, (c) using problem-
solving skills to overcome barriers to adherence and
consequently developing adaptive coping strategies, (d) es-
tablishing weekly personal goals, (e) increasing enjoyable
social interaction, and (f) discussing strategies to prevent re-
lapse. Participants who received the immediate intervention
condition showed signi“cantly greater reductions in caloric
and fat intake and weight as well as increases in the fre-
quency of blood glucose monitoring as compared to the con-
trol group. These results were maintained at the six-month
follow-up and were quite similar to the delayed intervention
group.
Glasgow, Toobert, and Hampson (1996) also conducted a
cost-effective medical of“ce-based intervention versus
standard care, which included computer assessments to pro-
vide immediate feedback on key barriers to dietary self-
management, goal-setting, and problem-solving assistance
and follow-up contact to review progress and facilitate prob-
lem solving to barriers. At the three-month follow-up, par-
ticipants experienced greater improvements in percent of
calories from fat, kilocalories consumed per day, overall eat-
ing habits and behaviors, serum cholesterol levels, and pa-
tient satisfaction (Glasgow et al., 1996). Improvements in
percent of calories from fat, serum cholesterol levels, and pa-
tient satisfaction were maintained at the 12-month follow-up
(Glasgow, La Chance, et al., 1997). Patient empowerment
programs seek to aid patients with goal setting, problem solv-
ing, stress management, self-awareness, effective coping
strategies, and motivation (R. Anderson et al., 1995). Find-
ings from the study conducted by R. Anderson and col-
leagues suggest that patients who received the intervention
were more self-ef“cacious and had a more positive attitude
toward their quality of life with diabetes. In addition, HbA1c
levels were lower in the intervention group as compared to
the control group.
Summary
Although it appears that the research on barriers to care, cop-
ing, and problem solving continues to be scarce, preliminary
evidence points toward the importance of assessing and
identifying personal and social-environmental barriers to di-
abetes self-care. The continued use of available assessment
tools that incorporate multiple or speci“c components of dia-
betes care, as well as the proliferation of other scales, will
greatly improve the current level of understanding barriers to
care and its impact on diabetes self-management. The inter-
vention studies reviewed demonstrate the importance of
including problem-solving skills to produce favorable psy-
chosocial and physiological outcomes. Therefore, future
research should include the continuous development of
interventions that incorporate active patient participation
programs in efforts to empower patients, optimize diabetes
self-care, and facilitate mental and physical health.SPECIAL ISSUES IN DIABETESSexual DysfunctionSexual dysfunctions in men and women are characterized by
disturbances in sexual desire and in the psychophysiological
components of the sexual response cycle (e.g., desire, arousal,
orgasm, resolution; Fugl-Meyer, Lodnert, Branholm, & Fugl-
Meyer, 1997). Sexual functioning is a complex phenomenon
that is best viewed from a biopsychosocial perspective
(Enzlin, Mathieu, Vanderschueren, & Demyttenaere, 1998;
Spector, Leiblum, Carey, & Rosen, 1993). Sexual dysfunc-
tions are widely believed to be multicausal and multidimen-
sional. It is dif“cult to identify cases with a purely organic or
purely psychogenic etiology, in part, because sexual dysfunc-
tion is often developed and maintained by a reciprocal
process in which organic factors (e.g., diabetes) lead to psy-
chological distress, which in turn exacerbates the organic
problems (Schiavi & Hogan, 1979).Sexual Dysfunction in Men with DiabetesThe consequences of diabetes on sexual functioning in men
are well documented. Although disorders of all phases of the
sexual cycle have been reported in diabetic men (Jensen,
1981), erectile dysfunction (ED) has received the most atten-
tion. An estimated 35% to 70% of men will experience ED at
some time during the course of diabetes, either intermittently
or persistently (Spector et al., 1993), and the prevalence may
be three times that found in the general population (Feldman,
Goldstein, Hatzichristou, Krane, & McKinlay, 1994). Possi-
ble etiologic factors include peripheral neuropathy, peripheral
vascular disease, and psychological factors (Rendell, Rajfer,
Wicker, & Smith, 1999). The severity of ED may also be re-
lated to both severity (Metro & Broderick, 1998) and duration
(McCulloch, Campbell, Wu, Prescott, & Clarke, 1980) of
diabetes. Although psychogenic factors, such as performance
anxiety, can contribute to the etiology of ED (Whitehead,
1987), organic factors are believed to be the predominant eti-
ology in diabetic men (Saenz de Tejada & Goldstein, 1988).
Autonomic neuropathy is considered to be the main etio-
logical factor in diabetic impotence due to damage both to